geriatric group art therapy

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Case Study: Geriatric Group Art Therapy

in a Nursing Home

By

Beth Ann Tramer, B.F.A.

A Thesis Submitted in Partial Fulfillment of

The Requirements for the Degree of

Master of Arts in Art Therapy & Counseling

Ursuline College Graduate Studies

May, 2008


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Ursuline College

Graduate Studies

We hereby approve the thesis of

BETH ANN TRAMER

candidate for the

Master of Arts in Art Therapy & Counseling Degree

Approved by:

___________________________________________________Dean of Graduate Studies

___________________________________________________

Director of Master of Arts in Art Therapy & Counseling Program

Reading Committee:

________________________________________

________________________________________

May, 2008


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Copyright 2008

Beth Ann Tramer

All Rights Reserved


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Acknowledgments

Many thanks are in order for making the completion of this case study

possible. The devoted staff of Ursuline College Art Therapy and Counseling

Department, Cecile Brennan, Gail Rule-Hoffman, Rick Rule-Hoffman, Amy

Jacobs, and Diane Meros, who have always been generous with their guidance

and support. Pat Janosko who has never wavered in her kind assistance. My

internship advisers, Ronna Posta and Sondra Radcliffe for their continued support,

and my thesis reader Laura Balliet for her constructive suggestions. The residents

of my nursing home site for the many lessons they have taught me. My mother,

Frances Tramer, for being my first geriatric art therapy client. My sister, Harriet

Tramer, for assisting in hours and hours of proof reading. To my son, Gerald Abt,

for being an ongoing joy and wonderful person. And, special thanks to my

husband, David Abt, without his support, understanding, and hours of work, this

thesis may never have been finished and my studies to be an art therapist and

counselor would never have been started.


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Abstract

Thesis Title:

Case Study: Geriatric Group Art Therapy in a Nursing Home

Beth Ann Tramer

This case study explores the benefits of group art therapy during 15 one

and a half-hour weekly sessions in a nursing home. The participants, all from

middle class backgrounds, were Caucasian females with the exception of one

African American male. Ranging in age from 72-95, all faced a variety of

physical and cognitive challenges. In an effort to give all the participants a

meaningful experience, the art as therapy approach presented a broad scope of art

materials and skill level tasks. These well-received sessions focused on

socialization, enhancing self-esteem, reminiscing, and creative decision making,

while reinforcing manual and visual dexterity. A review of literature that

discussed geriatric art therapy research, conclusions, recommendations and

proposed future research are included. This case study determines that art therapy

with the geriatric population has great promise as an alternative complementary

therapy, worthy of further study and continued practice.


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Table of Contents

Page

Approval Page ii

Copyright iii

Acknowledgments iv

Abstract v

List of Figures viii

I. B. Singer Quote 1

Chapter I Introduction 2

S. McNiff Quote 7

Chapter II Procedures 8

H. Matisse Quote 17

Chapter III Literature Review 18

Gates of Repentance Quote 34

Profiles of Art Therapy Group Members 35

Chapter IV Sessions 1 - 7 38

Anonymous Quote 78

Chapter V Sessions 8 - 15 79

Dostoevsky Quote 112

Chapter VI Conclusions and Recommendation 113

Poem 125


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References 128

Appendixes Appendix A: Art Therapy Release Form 132


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List of Figures

Page

Figure 1. Hazels Mandala. 42

Figure 2. Velma's Mandala. 44

Figure 3. Go Home Lost. 48

Figure 4. Bernice's Stars at Nite. 51

Figure 5. Bernice's Bugs Are Coming. 54

Figure 6. Vivian's Bugs in the Forest. 55

Figure 7. Ellen's Stamp Art. 56

Figure 8. Deborah's Person in the Rain. 60

Figure 9. Bernice's Rain Rain. 61

Figure 10. Annette's Person in the Rain. 63

Figure 11. Bernice's A Mess. 67

Figure 12. Annette's Windstorm. 68

Figure 13. Bernice's Iris. 70

Figure 14. Pink Styrofoam Dish. 71

Figure 15. Deborah's Flowers. 72

Figure 16. Bernice's For the Birds. 74

Figure 17. Deborah's Confetti. 75

Figure 18. Hazel's Drawing. 76

Figure 19. Adena's Flowers. 80


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Figure 20. Bernice's Rainbow. 83

Figure 21. Hazel's Watercolor. 84

Figure 22. Velma's Check Girl. 86

Figure 23. Vivian's Day at the Beach. 88

Figure 24. June's Rainy Day at the Beach. 89

Figure 25. June's Monet Watercolor. 94

Figure 26. Annette's Watercolor. 95

Figure 27. Celia's Tree of Life. 97

Figure 28. Annette's Tree. 98

Figure 29. Deborah's To Want. 100

Figure 30. Marjorie's Earth, Air, Fire,Water 103

Figure 31. Hazel's Earth, Air, Fire,Water. 104

Figure 32. Vivian's Earth, Air, Fire,Water. 105

Figure 33. Vivian's Hat. 109

Figure 34. Celia's Hat. 110


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1

The instinct to create remains as long as one breathes.

Isaac Bashevis Singer

Winner of the 1978 Nobel Prize for Literature, who continued to write

until his death in 1991, at the age of 87.


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Chapter I

Introduction

Statement of the Problem

The United States Census Bureau states that by 2050 there will be more

than 32 million people over the age of 80 in the United States (United States

Census Bureau, 2005). The world has never previously experienced such a

phenomenon. This population will require mental, physical and emotional care to

an unprecedented degree. Those 85 and older will reside primarily in assisted

living and nursing homes. Isolation, anger, loneliness, fear of abandonment by

family, frustration, and feelings of being unloved are some of the issues they will

face daily (Berman, 2005). Depression, common and often unrecognized, plagues

this population (United States Census Bureau, 2005). Physical conditions such as

heart disease, diabetes, cancer, and Parkinsons disease can mask depression.

According to the National Mental Health Association (2003), depressive

symptoms occur in about 15 percent of community-dwelling older people and up

to 25 percent of those living in nursing homes (United States Census Bureau,

2005, p.48). Many of the difficult issues faced by this population could be

reduced by art therapy interventions which were constructed, created and

developed specifically for this population (Rusted, Sheppard, & Waller, 2006). Purpose of the Study

The purpose of this qualitative case study is to explore appropriate and


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successful art therapy interventions performed with the residents of a nursing

home during group art therapy sessions. This study employs a variety of

interventions and mediums in an effort to examine which art tasks offer an

opportunity for the resident to find peace and enjoyment, creative decision

making, reminiscing, esteem building, enhancement of socialization skills, and

decrease of depression, loneliness, anger and isolation. The art therapy sessions

also have the potential of improving the residents physical health as their mental

outlook improves. A change in the mental outlook and attitude of the residents

enriches their relationship with the staff. If the staff is more comfortable with the

residents and able to communicate on a higher functional level, they will be able

to more successfully and efficiently facilitate the needs of the residents. This will

result in their experiencing greater professional fulfillment and satisfaction. A

positive relationship between staff and resident is beneficial to the happiness and

well being of both parties.

Research Questions

1.) What are the most beneficial expressive, creative art activities to

include in a group art therapy session of mixed skill level, (cognitive, physical

and emotional) seniors in a nursing home environment?

a) How does the level of difficulty for each activity affect the

participants?


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b) What is the estimated length of time for each activity?

c) What are the supplies needed to accomplish the art task?

d) How are the appropriate tasks selected?

2.) What is the appropriate level of explanation for each activity?

a) How is the information for participating in the art task conveyed to

the residents to both interest and involve them?

b) When is it appropriate to show examples of work before the project

begins?

Definition of Terms

Some terms are repeatedly used in this case study, and are identified

and defined as follows.

Alzheimers Disease. Alzheimers disease is a slowly progressive form of

dementia. Memory impairment as well as the loss of adequate language ability,

difficulty with decisions, judgment, attention span or other significant cognitive

functioning, might precipitate a diagnosis of Alzheimers disease.

Art Therapy. Art therapy is a nonverbal and creative outlet for expression

of feelings and issues. This process often allows for a bond between therapist and

client that has therapeutic value in leading to behavioral change involved in a

psychic/creative level other than that of talk therapy alone.

Creativity. Creativity is the ability to invent, produce, make, or bring into


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being something new.

Dementia. Deterioration of mental functioning, involving impaired

memory, thinking, judgement, and language (Nevid, Rathus, & Greene, 2003, p.

432).

Depression. Depression can affect emotional states causing feelings of

sadness, irritability, or tearfulness. It can change levels of motivation, which can

be seen in reduction of socialization, enjoyment, activity or verbalization.

Depression may be seen in changes of appetite, sleep, weight, and level of

functional abilities. The risk of depression is a major problem faced by many

older adults and prevalent among residents of nursing homes.

Geriatric Population. A geriatric population is comprised of male or

female persons 70 years or older some or all of whom have medical needs that

must be under constant attention.

Mini Mental State Examination. (MMSE) The MMSE is a brief 30-point

questionnaire with a time span of about ten minutes. It is administered to assess

cognitive ability and commonly used to screen for dementia. A score over 24 out

of 30 is effectively normal. A score of 23 or lower indicates cognitive

impairment.

Nursing Home. A nursing home is a facility that provides full-time nursing

coverage, including: assisted bathing, dressing, walking, eating and other


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therapeutic needs for the residences.

Process. Yalom (1995) states that from a psychotherapeutic aspect process

is defined as the nature of the relationship between interacting individuals,

(p.130). Wadeson (1995) states, In group art therapy, process may become

illuminated through images as well as words and additionally through reflection

on the images, (p.147).

Senior/Older Adult, Elder. A male or female person aged 70 years or over.

Stress. A level of tension and unpleasant feelings involving situations that

seem too difficult to control.

Delimitations and Limitations

The major delimitation of this study was that the majority of participants

were all Caucasian females from a middle class socioeconomic background. They

participated on a volunteer basis. This is a limitation as it may have only attracted

participants who were interested in the activity, and therefore make no claim as to

the benefits of the art activity for persons who are unfamiliar or uninterested with

such activities. Only one male volunteered for the art therapy sessions.


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''Art is not limited to one cognitive, cerebral channel. It's an

interplay between all the senses, and so it can engage people

wherever they happen to be."

Shaun McNiff

Past president of the American Art Therapy Association

and the author of several books about art therapy.


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Chapter II

Procedures

Characteristics of Qualitative Research

Qualitative research uses interactive methods of data collection, which

allows for a humanistic approach. The research is conducted in the participants

natural setting, affirming a sensitivity and involvement between participant and

researcher. I was closely involved with the participants and experienced their

world. My involvement was accomplished through the art therapy interventions as

well as talking and visiting when taking participants to and from their rooms,

before and after the art therapy sessions. Qualitative research is not tightly

structured in the early stages. As data is collected new questions and aspects of

research emerge. Creswell (2003) states, The more complex, interactive, and

encompassing the narrative, the better the qualitative study (p.182). Collecting

data, analyzing and interpreting simultaneously allows for themes, which may

develop and change, leading to more research. The process is multifaceted,

interactive and simultaneous (Creswell 2003).

My personal interpretation entered into the data analysis process.

Therefore, this type of research is subject to personal involvement, values and

interests of the researcher. This is recognized as a characteristic of qualitative

research.


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Qualitative Research Strategies

I used a qualitative case study as the strategy of inquiry. This case study

explored the processes, activities and events of nursing home residents as they

experienced 15 consecutive art therapy sessions. To allow for freedom of

expression, whether verbal or visual and to provide an atmosphere of safety and

support, the sessions were conducted in a very flexible manner. Each session

incorporated a different art intervention and a variety of art materials were used,

such as, markers, watercolor paint, stamps, and colored paper for three-

dimensional objects.

Role of the Researcher

One of the characteristics of a qualitative case study is the close personal

involvement that the researcher has with the study. Consequently, it is essential

that the researcher remains aware of and concerned with biases and values about

ethical and personal issues, which are reflected in the research outcomes. The

researcher must identify these issues and how they might influence the research

topic, data collection, and analysis.

Part of my Internship requirements in completion of my Master of Arts in

Art Therapy and Counseling were fulfilled at a nursing home in a suburb of a

large Midwestern industrial city. At this time I was privileged to participate in

weekly art therapy sessions. I observed that many residents faithfully attended

these sessions and looked forward to the myriad of art interventions, the


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opportunity for socialization and creativity as well as the interaction and special

attention I extended to them. The art therapy activities differed greatly from the

other offered activities. Regular offered activities such as movies, performances

or lectures only allowed the residents to be observers or verbal participants not

active members. As the art therapy sessions proceeded the residents became

aware that they were consciously controlling the creative process as they

developed artwork with their own hands. They were active members of the group.

Our sessions encompassed the physical, mental and emotional aspects of each

individual. The spontaneity, and the you cant do anything wrong, approach

which permeated these sessions were unique from the other activities of their

planned day. It is my belief that art therapy with older adults in a nursing home

setting is crucial to their physical, emotional, mental and spiritual well being. My

personal belief is that the residents greatly benefited from the art therapy sessions

though I attempted to analyze this case study in the most objective manner

possible.

Data Collection Procedures

Setting. The study was conducted in a nursing home located in a suburb of

a large Midwestern industrial city. I completed my Internship requirements for a

Master of Arts in Art Therapy and Counseling at this facility. There were

approximately 80 residents in this well maintained nursing home facility. I

introduced weekly art therapy session which took place in a large rectangular


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room 25 by 12. Thanks to large windows and electric lighting the room was well

illuminated. There was easy access to a sink and toilet area. The artwork was

produced at two centrally located rectangular tables. The room also allowed for

easy wheel chair accessibility. All the data was collected in this setting.

Participants. All of the volunteer participants were residents of the

nursing home. They decided whether they wished to attend the sessions, for how

long, and on how regular of a basis. They ranged in age from 72-95. Most of the

group were from middle class socioeconomic backgrounds and consisted of one

African American male, and Caucasian females. The physical challenges

characteristic of each participant are noted in the individual case study sessions.

Many suffered from failing eyesight and hearing, dementia and arthritis.

Most of the participants were in wheelchairs, which often predetermined

where they sat around the table. The group members were allowed to sit wherever

they wished, but often took the same position for every session. All the data was

collected in this room.

Methods of gathering data. Data was collected by observation of artwork

completed by the participants. All of the artwork was produced during art therapy

sessions. I observed the artwork and the process taking place during the art

activity. My attention was focused on the appropriateness of the intervention.

Special regard was given to: the attention span needed to complete the activity,

the ease of understanding the directives, and the physical ability necessary to use


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the art materials. I also discussed with the participants as a group their reactions to

and thoughts about each activity. The interaction of the participants was observed

and accurately annotated and documented after every session. My documentation

helped me to determine if the sessions were meeting their goals of promoting and

enhancing socialization skills. Yalom (1995) states:

Frequently senior members of a therapy group acquire highly

sophisticated social skills: they are attuned to process; they have learned

how to be helpfully responsive to others; they have acquired methods of

conflict resolution; they are less likely to be judgmental and more capable

of experiencing and expressing accurate empathy (p.16).

Data Analysis Procedures

The data was explored in an ongoing process determining that the research

questions were appropriate and that art tasks corresponded to the population and

their setting. I implemented all of the tasks with the participants. Consequently, I

was able to witness many important elements of the actual process: the ease with

which the participants followed directives, the ease with which the participants

used the art materials, and the participants ability to complete the task. I observed

participants emotional expressions both verbally and kinetically in response to

each session.

There were a total of 15 sessions, and the group met weekly on Tuesdays

from 10:30 a.m. until 12 noon. The sessions varied in number of participants from


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6 to 12. No one participant attended all the sessions. Participants missed sessions

due to other appointments such as the doctor, the beautician, and the physical

therapist. Illness or tiredness were also a cause of absence. There were regular

attendees and these are noted in the session reports. All the artwork was

documented in the form of digital photographs. Many of these photographs are

used within the body of this paper to illustrate examples of the artwork. Although

staff members were not asked to officially report feed back concerning the

sessions, many nurses, aides, and activity personnel verbally commented on the

sessions beneficial effects. The accounts of each art therapy session are described

in this case study.

Strategies for Validating Findings

After each session I documented my observations, the participants

comments, thoughts, reactions, and artwork. The artwork and documentation of

sessions were then validated through weekly reviews, critiques and discussions

with professionals in the field. Reviewing data frequently as the study progressed

allowed for ongoing changes and clarification.

The findings that occur during the study can be compared to experiences

documented in literature. This comparison serves as a reference point to validate

the explorations of the present study. Findings that run counter to the research and

findings that are in agreement with the anticipated research were reviewed.


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Narrative Structure

The narrative that emerged from this case study documented 15 art

therapy sessions. The materials used, the goals established, and the resulting

artwork, thoughts, comments and feedback from the participants comprise the

data of this study. After reviewing existing literature as noted above I selected

tasks that appeared to have the greatest potential for success. These tasks were

used in the sessions. The art tasks were changed and evolved as I observed their

appropriateness for the group. I also took into account the participants requests

and suggestions. Examples of artwork and actual statements from participants are

included in the body of the text. Conclusions and recommendations are noted as a

result of the case study.

Anticipated Ethical Issues

A qualitative research case study has by nature the need for anticipated

ethical considerations. Creswell (2003) states, First and foremost the researcher

has an obligation to respect the rights, needs, values and desires of the

informant(s) (p.66). All names of participants have been changed to protect their

identity and privacy. The participants were all volunteers and provided

information willingly to me for the purpose of this study. All participants signed a

release form consenting to the use of their artwork. A copy of the client release

form is in Appendix A: Art Therapy Release Form.


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Significance of the Study

Art therapy with the geriatric population is gaining recognition as a

complementary alternative therapy, which has health giving effects on a physical,

cognitive, and emotional level. This case study stands as a tribute to the ever-

growing need for greater importance and acceptance of this work. In this study I

have demonstrated that the geriatric residents of a nursing home have the capacity

to fully participate, enjoy and grow from art therapy. These group members and

their experience serve as an educational review of the processes and artwork

applicable in this setting. Hopefully this case study will inspire art therapists or

other clinicians working with this vibrant population to find joy and share in arts

therapeutic benefits.

Expected Outcomes

Though I am aware that documenting 15 sessions is a relatively short

period of time for a thorough case study, it is my hope that even within this time

frame the study will reveal the benefits of art therapy with geriatric nursing home

residents. Potential benefits include: improved self esteem, enhanced socialization

skills, reminiscing, finding joy, pleasure and relaxation, and stimulating cognitive

awareness. For an hour and a half the residents can forget the many challenges

and losses they face and enter a world of creativity and special relationships,

established with each other, with the art therapist and with themselves. Using

appropriate art tasks and therapeutic awareness enables the residents to experience


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an activity that is unique and meaningful to them.


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Because of his health,

it became increasingly difficult for Henri Matisse to work.

In spite of this, he did some of his largest and most famous

cutouts while confined to a wheel chair during his last

two years before death in 1954 at the age of 85.

Henri Matisse was considered one of the greatest artists of the 20th

century.


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Chapter III

Literature Review

Theoretical Basis for using Art Therapy with the Geriatric Population

Art as therapy, is based on the belief that the creative process involved in

the making of art is healing and life-enhancing (Peterson, 2006, p.115). Whether

we make an image of our bodies in the snow or cover our parents walls with our

crayon masterpieces, expressing ourselves through the arts is a health giving

activity. In fact, Abraham Maslow (1968) and Carl Rogers (1961) conclude that

self-actualizing creativity seems to be synonymous with health itself. This is no

less true at the age of 9 or 89. Essential to our being, the act of creating separates

us from other animals and enhances our relationship with each other, our

environment, and ourselves. Research shows that creativity is alive and well in

older individuals and may even be resurgent in older age (Simonton, 1990).

Erik Eriksons (1959) research on age-related developmental tasks and needs

offers an important directive in creating successful art therapy tasks for older

adults. Each stage of life has challenges that must be met; achieving each

developmental goal remains paramount to integrity with and engagement in the

world. The Eriksonian developmental stages present the elderly as facing a

dichotomy between integrity vs. despair. According to Erikson (1959) successful

resolution of this tension is essential. Isolation, despair, depression, and

hopelessness can negatively affect people who do not pass through this process.


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Research has found depression to be widespread among the elderly, impacting

negatively upon the health related quality of their lives (Shumuely, Baumgarten,

Rovner, & Berlin, 2001). Depression not only affects mood by expressing itself as

sadness, unhappiness, anxiety or irritability, it can also result in loss of interest,

difficulty concentrating, suicidal ideation, low self-esteem, negativity and guilt.

Behaviorally, depression often presents itself as psychomotor retardation,

agitation, crying, social withdrawal, clinging, and attempted suicide. Nursing

homes report that 25%-40% of their residents suffer from depression, which is

more commonly found in women (Gerstenlauer, Maguire, & Wooldrige, 2003).

However, the physical and mental decline that accompanies this condition can be

counteracted by proper diagnosis and treatment (Rose, 2001).

Activities, such as art therapy, support creativity and productivity; these

activities maximize cognitive functioning and emotional well being. Shore (1997)

believes that even severely impaired individuals can use the creative process to

find a new capacity for wisdom. Art therapy achieves these objectives at the same

time as it bolsters cognitive orientation, physical well being, motor skill

maintenance, acceptance of life change and loss, reminiscence, and socialization

skills. Importance is placed on the meaningfulness of the task and not on the

actual product. Art making supports the emergence of expressiveness that

depression mutes and offers opportunities for satisfaction and goal fulfillment

(Peterson, 2006, p.126).


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Art therapy represents an excellent form of communication with older patients

who because of dementia can no longer communicate using language. Art allows

expression of self and provides for a sense of mastery and control (Remington,

Abdallah, & Melillo, & Flanagan, 2006, p.190). Gerdner (2000) states that

through the use of colors, shapes, and textures found in art therapy interventions

the geriatric patient can awaken sensory stimulation. The art therapist is

challenged to find the intervention that is appropriate for each patient. The use of

crayons, for example, might seem childlike but if presented with sensitivity they

may evoke pleasant memories and establish a basis for reminiscence.

Gene Cohen, M.D., founder of the Center on Aging and a leader in research

involving creativity and aging, is a proponent of two new ideas that have recently

emerged: age associated problems are modifiable and the aging process can be

potentially successful and life enriching. He has found that people often have a

greater potential for artistic expression during the second half of their lives

(Cohen, 2006). Elizabeth Layton exemplified this point when she began painting

for the first time at 68. To her surprise and elation she found she excelled at

drawing. She continued producing her art for the next twenty years and received

recognition and fame. Through her self taught art therapy, she managed to end her

life long battle with depression.

Cohen (2006) has identified four mechanisms which influence the context of

creativity and aging: a sense of control, influential brain activity, benefits of


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socialization, and brain plasticity. The first mechanism, a sense of control, might

be summarized as follows. Nursing home residents have limited control over their

lives. The creative decision making involved in forming a work of art helps to

give them back this sense of control. The color, size, shape, medium, self

expression, and subject matter that distinguish a piece of art are controlled by the

artist. Opportunities to create something new and beautiful are endless and this

offers a sense of satisfaction and empowerment.

The influence that the mind holds over the body represents the second

mechanism. Scientists have found that the positive feelings associated with a

sense of control trigger a response in the brain sending signals, which strengthen

the immune system, fostering improved physical well being. This vital sense of

control which promotes immune system health can be encouraged by creative

decision making regarding personal art.

Benefits which evolve from socialization represent the third mechanism. Art

therapy in the nursing home environment is usually conducted in a group therapy

session. Group members creating together have an opportunity to interact socially,

dialogue about their art, and discuss the past, the present, and the future. The

group members gain a feeling of acceptance and support from each other. This

type of interaction and social engagement in the second half of life has been

shown to reduce stress and blood pressure levels (Cohen, 2006).


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Art therapy activities continuously offer challenges, which can increase brain

plasticity, the fourth mechanism influencing the context of creativity and aging.

When new activities and surroundings challenge the brain its reserves are

enhanced. Participants of the art therapy group learn new techniques, remember

old ones, make decisions, explore new worlds of visual expression, and often look

deeply into themselves to answer unanswered questions in their lives, which may

have remained hidden for years. Activities such as these challenge the brain. Art

activities are also often sustained over a number of sessions; such ongoing

activities challenge the brain, fostering brain plasticity (Cohen, 2006).

In his neuroscience research on the creative brain and dementia; Bruce Miller

M.D. (2006) has found that the degeneration of certain areas of the brain produces

amazing results by releasing previously dormant cognitive abilities in other areas.

Many individuals who never created art before their illness are now finding they

can make intriguing artwork. An explanation for this occurrence may be

explained by the understanding that different parts of the brain may take over to

compensate for a brain area that is no longer functioning. Visual expressions in

areas such as drawing, painting, or sculpting may survive even after a person

loses their capability for verbal language.

Older people in general and especially those in nursing homes may feel useless

and as if they are no longer a viable part of our society. This may occur because

our culture appears to praise youth. Connecting with the elderly brings us closer


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to our own aging process and our inevitable death. John Tyler, Head Art Therapist

at NHS Trust Hospital in Surry, UK (2002), suggests that the elderly become

persona non grata. No longer feeling like an important member of society, or

someone who is respected and needed, is one of the many painful losses

associated with old age. Other losses include: employment, cognitive skills,

independence, personal loss of family and/or friends, and in some cases, their own

identity. Grieving these losses may not always be expressed in words but, the

possibility of art therapys non-verbal process offers older people increased

control over their lives and expression of loss.

As older people explore the use of art materials, they can organize their

experience in their own way with personal images and meaning. The act of

making art encourages people to be themselves, free from external expectations,

and this has the ability to offer empowerment. It may be rare for this older

population to freely express and explore their feelings. Tyler (2002) praises art

therapy for encouraging participants to return to happy memories of their

childhood through their artwork. Completing artwork fosters a sense of

accomplishment and achievement. Gaining acceptance and understanding of loss

through the artwork is also a benefit of art therapy.

Research on the Benefits of Art Therapy for the Geriatric population

Cohen (2006) conducted research designed to measure the physical,

mental and emotional benefits of art and cultural programs. The results after a


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year into the study showed that the art groups, in contrast to the control groups,

exhibited areas of stabilization and improvement. These findings led Cohen to

assert that community based arts programs for older adults could help reduce risk

factors that contribute to the need for long term care.

B.T.Hannemann (2006) concurs with Cohens findings. Using art as a means

to explore the many facets of lifes experiences, which may emerge in old age,

Hannemann (2006) notes, Creativity is the key to find the way from our inside to

the outside (p. 65). He researched the effect of art therapy on dementia patients

in Great Britain, Sweden, Japan, and Brazil, concluding that art therapy helps

reduce depression, improves sensory processing and encourages participants to

feel more secure in making their own choices and decisions. Hannemann refutes

the commonly held idea that creative ability is weakened in old age. On the

contrary he believes that due to their more extensive life experiences, older people

may often develop their ability of creativity and imagination to a higher level than

younger people.

Rusted, Sheppard and Waller (2006) conducted a 40-week study that

compared art therapy groups and activity groups that did not have emotional

expression as a central focus. Utilizing nursing home residents as subjects, this

research concluded that art therapy positively benefited people with dementia in

regards to their mental alertness, sociability, physical and social engagement.


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These benefits were not observed to the same degree amongst participants in

programs that used recreational activities exclusively.

Kinney and Rentz (2005), observed individuals in early and middle stages

of dementia while they engaged in Memories in the Making, an Alzheimers

Association program that encourages self-expression and enhanced well being

through the visual arts. The well being of the study group was compared to the

well being of a control group that participated in more traditional adult day care

activities. Memories in the Making examined participants experience regarding:

(1) sensory stimulation; (2) pleasure involving the creative process; (3) sense of

well being; (4) increased self-esteem.

Kinney and Rentz (2005) acknowledged there were limitations to the

study. The sample size, 12 was too small for conclusive accurate results and other

activities were also rated on the same day. After the Memories in the Making

session, the participants lower well being scores might have been attributable to

fatigue. A large amount of training was also necessary to accurately rate the

established well being scale. Inaccurate reports were possible.

Kinney and Rentz were, however, still optimistic about this area of research.

Participants demonstrated significantly more interest, sustained attention,

pleasure, self-esteem, and normalcy while they were part of Memories in the

Making. Relatively little negative affect or sadness, important components in

evaluating the well being of the participants, were observed. The study raised


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additional questions: (1) what is it about a particular activity that brings pleasure

and ensures engagement; (2) does the art process tap into areas of the brain that

are unaffected by the disease; (3) is there a sense of well being that comes from

the regularly scheduled failure free activity with peers, or is the attention of the

facilitator important? Kinney and Rentz (2005) acknowledge that the answers to

these questions are beyond the scope of this research. They maintained, however,

that their research opened the door to future study regarding a growing number of

alternative therapeutic interventions promoting well being for individuals with

dementia illnesses.

Art Therapy in Practice with the Geriatric Population

Attilia Cossio (2002) is an art therapist who trains staff and leads art

therapy groups with elderly people in Milan, Italy. In her lectures titled, When

drugs are not enough and words are useless she explains the alternative and

complementary aspects of art therapy. She notes that participants brighten when

they observe the inherent beauty and harmony in their work. It appears that

dementia has not destroyed sensitivity and intuition, which are revealed in the

artwork. She also credits artwork with liberating emotions, feelings and thoughts.

Cossio also maintains that participants in art therapy sessions become a

support group for each other, with interactions and dynamics unfolding along a

common pathway. The groups joint efforts emphasize the values of sharing,

interpersonal interaction and socialization. Completing art projects may, likewise,


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enhance the individuals creative self, and counteract depression. The healthy

functioning aspects of the individual maybe activated which promotes harmony in

the person as a whole, and eliminates the singular identity of just someone with

dementia.

Mary Baird Carlsen (1991) is well known for her foresight in exploring

creativity with elders. She is a strong advocate of the creative potential which

does not have to wither, but grows richer and deeper as we age. She cited citing

examples of people in their eightieth year who spoke of their lives and their work

not their age. She acknowledged the difficult challenges of aging: the

deterioration of physical and mental capacities, the loneliness, the depression, the

abandonment by society, and the bias of ageism (Carlsen, 1991). But, she

maintains that with unique therapy sensitive to this population, the elderly may

live creative, positive lives, and may also serve as people of wisdom, guiding and

inspiring us. She encouraged the importance of developing a world in which

aging creatively with meaning is worth our thoughts, our dedication and remains

within our goals.

Kathy Kahn-Denis, an art therapist who practiced in Cleveland, Ohio, was

known for her work with the geriatric population. She found that the evocative

nature of art allows older adults with dementia to become expressive, bypassing

some of their cognitive deficits. This expressive nature of artwork allows the

release of unexpected feelings, which gives the art therapist/witness an


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opportunity to see the feeling person without layers of confused thought or

isolation. Kahn-Denis (1997), witnessed art therapys effectiveness with the

geriatric population for the following reasons: (1) it assists with diagnosis and

evaluation of cognitive status; (2) it provides a vehicle for nonverbal

communication; (3) it offers an opportunity for reminiscing; (4) it enables sensory

exploration and stimulation; (4) it provides a self-reflective activity resulting in a

tangible end product of the artwork itself.

For more than 13 years, Elizabeth Cockey (2007), an art therapist has been

using art therapy to improve cognitive memory, coordination, the ability to accept

lifestyle transitions and mental outlook in persons with Alzheimers disease.

Cockey felt satisfaction in being able to offer art therapy as a way to ease the

suffering of those who struggle with the disease and its effects. She has witnessed

many positive effects of her work as an art therapist with this population. Cockey

has gone on to offer workshops and seminars in which she trains other health care

professionals so that more individuals may experience the benefits from art

therapy.

John Zeisel, president of Hearthstone Alzheimer Care, which operates

residences for people with Alzheimers disease in Massachusetts, New York, and

Connecticut, maintains that art and other multisensory experiences may help

patients tap into memories the disease has shrouded but not stolen. Zeisel has

found that art can change emotions toward a positive direction very quickly.


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Working from the theory that art can be used as a therapeutic tool, Hearthstone

has been instrumental in initiating visits to the Museum of Modern Art in New

York and the Museum of Fine Arts in Boston, outings that seem to have a positive

impact.

In evaluating the museum experience, Kennedy (2005) notes that Oliver Sacks,

a famed neurologist in the area of dementia and the arts, has often witnessed

patients in later stages of dementia respond vividly and delightfully to paintings at

a time when they could no longer use words. Hearthstone staff members found

that the residents moods improved for hours and even days after the museum

visit. Sacks maintains that the museum visits achieved these results by tapping

into procedural memory which remains intact long after the onset of dementia

(Kennedy 2005).

While there is no research demonstrating that art therapy cures

Alzheimer's patients, there is anecdotal evidence that it may reduce the agitation

and aggressiveness the disease can cause (Schworm, 2006). Art therapy cannot

halt or reverse the progression of the degenerative brain disease, which gradually

impairs the ability to think, remember, and communicate. Results such as those

seen by the staff at Hearthstone lead researchers to believe that art therapy may

engage the mind's expressive and emotional facilities that remain intact, and

consequently improve patients' quality of life.


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Hodges, Keeley, and Grier (2001) conducted a study over a period of

four years to evaluate the affect of art masterpieces on the chronically ill elderly.

The study also analyzed perceptions about chronic illness among three different

groups: registered nurses, nursing students, and the elderly. The elderly in the

study were comprised of individuals 62 years and older, who were cognitively

intact and were capable of performing daily living skills. The research identified

nine distinct themes of observation from the three groups: role change, sadness,

isolation, decreased communication, adaptation, acceptance of self, fear, need for

support, and hope. The most distinct difference between the groups was a focus

on hope, which was expressed only by the elderly adult group.

Slides of artwork used in the study included: Van Goghs painting of

Flowering Peach Tree, Munchs paintings The Dead Mother and Child and

The Scream, Goszs painting A Married Couple, and Abakanowiczs sculpture

Cage. Hodges et al. (2001), found that viewing masterworks of art and

discussing them together served as a catalyst for communication between the

nursing staff and the elderly.The visual images provided a neutral medium for

discussion that enhanced more meaningful disclosure about the personal

experiences of illness.

Gerstenlauer, Maguire, & Wooldrige, (2003) found that depression among

nurses can be triggered by patients with Alzheimers who become increasingly

more dependent. The need to keep nurses, especially those who work with


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elderly, satisfied and gratified in their work is paramount (Hodges et al. 2001).

Often patients are not able to communicate their needs or feelings, creating

frustration for both parties. The benefits patients gained from their exposure to the

masterworks of art granted nurses a new avenue toward forming a positive

relationship with their patients. A greater chance for success and fulfillment in

working with their patients was available through this shared reality. This

translated into heightened job satisfaction and potentially into increased retention

rates, which resulted in the well being and health of both parties.

Both the Hearthstone museum trips and the act of viewing and discussing

art (Hodges et al., 2001) focused on inspiration found by incorporating others

artwork into their own lives. These creations provided illuminating views of

human experiences. Art has long been a medium for communicating the very

essence of what it means to be human. Results from the Hearthstone museum trips

as well as the research of Hodges et al. indicate that the act of viewing art has the

power to influence well being and positive change, in the elderly with debilitating

illness.

Britt-Maj Wikstrom (2003) explored a study at a nursing home in Sweden

which was similar to Hodges et al. (2001). Health professionals employed visual

art as a conversation tool with the elderly. The paintings they utilized portrayed

flowers, landscapes, and playing children. Participants were asked to use the

paintings to initiate and establish conversations with the elderly and to keep


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diaries that detailed their experiences (Wikstrom, 2003). The elderly viewed

some art works and were then asked the following questions: (1) Which of these

pictures of works of art capture your interest? (2) What does it bring into your

mind?

Data acquired from four months of diary entries by the healthcare staff

indicated that viewing artworks may prove instrumental in helping them interact

with patients. They concluded that (1) It was a tool to get close to the elderly

person. (2) Many times the elderly person took the initiative and directed the topic

to be discussed. (3) New ideas of what to discuss arose during the conversation.

(4) The elderly persons reflected spontaneously on sad and happy life events.

Caregivers also reported that they gained a deeper understanding of the elderly

and their circumstances. Many caregivers reported that they felt more satisfaction

from their work and enjoyed the time spent with the patient, making the

challenges they faced within a nursing home setting less daunting. As in the

Hodges et al. (2001) study the caregivers experience of enhanced well being

reverberated throughout the entire institution.

The Sandwell Third Age Arts, an independent charity in the United

Kingdom brings art activities to older people with dementia. Sharon Baker

(2006), an artist who directs the organization believes that her role is simply, to

bring creativity, fun and pleasure into the lives of people who are often, isolated,

confused, lonely and depressed. Baker found that dementia, had rendered


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dormant, active skills of long ago. Awakening these skills through art had the

potential to give back a sense of self. Baker witnessed that participation in the art

program resulted in therapeutic benefits such as positive stimulation, enhanced

communication, experimentation in a safe environment, heightened self-esteem

and confidence, and help with relaxation. She believed that if people enjoy the

experience, it has been worthwhile. It is about the process of making the art,

rather then solely the end product. Pleasure for its own sake, regardless of mental

or physical capabilities was Bakers goal. Baker also cited the important benefit

that art may improve the relationship between the person with dementia and their

care provider. Hodges, et al. (2001) and Wikstrom (2003) also substantiated this

benefit in their research. If the person being cared for is happier and more content

the role of the care provider is more rewarding. The relationship may be healthier

and more enjoyable for both parties.


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Do not cast us away when we are old: as our strength

diminishes, do not abandon us.

Quote from Gates of Repentance, a prayer book used in

Reform Jewish Congregations.


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Ellen. Ellen, age 91 was only with the group a short time before

contracting a serious infection. Her out spoken negative remarks mixed with her

kindness, was a bitter sweet combination.

Hazel. Hazel was 93 and her greatest challenge during the sessions was

her hearing loss and increased depression. Her bright blue eyes and warm smile

were endearing, but her physical problems escalated during the course of this

study. She was a prolific artist, once I wheeled her into the room and gave her

paper and markers she entered her own private world and completely covered a

page with symbols, and shapes that were magical and uniquely hers.

June. June, age 83 was cognitively alert and always ready with thoughts

and suggestions to enhance the sessions Her confinement to a wheel chair and

physical condition were difficult challenges for her. She was a fine artist as well

as a writer and a poet. She was dedicated to the sessions and always gave the task

100 percent of her effort.

Marjorie. Marjorie, age 86 suffered from the early stages of Parkinsons

disease. Fortunately, she was still physically and mentally capable. She found a

special place in our sessions by being my helper, when it came time to cleanup.

Due to her physical and cognitive abilities she was able to collect materials from

the table and help wash brushes and paint dishes. She was the only person in the

group able to complete this skill.


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Paley. Paley, age 76 was the only male in the group and the only African

American. He was physically capable, walking unassisted. His challenges were

cognitive. Though his attendance was tentative at first, he soon became a regular

participant. He was a slow, careful, deliberate worker. Once he began a project, he

wanted to see it to completion.

Velma. Velma, age 89 was in excellent physical condition and able to walk

and dance unassisted. For this reason she entered and left the sessions at will,

sometimes staying for 15 minutes only to return 15 minutes later. She usually

spoke in Czech and was trying desperately to communicate through her art. Her

dementia made this a difficult challenge.

Vivian. Vivian, age 86 was the only member of the group in an electric

wheel chair. She was soft spoken, cognitively alert and had been a portrait artist.

Her keen eye and art experience added a special esthetic awareness to the group.


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Chapter IV

Sessions 1 - 7

This case study took place in a nursing home in the suburb of a

Midwestern city. All of the participants were Caucasian females, except for one

African American male. The sessions were conducted in the same wheelchair

accessible room, which measured 25 by 12, and was used for meals and other

activities, but during the art therapy sessions, the room was used only for that

purpose.One of the long walls had large windows that provided a view of trees

and grass outside. Between the windows and electric light the room was well

illuminated. There was also access to a sink and toilet area. A small area of

cabinets, housed limited art supplies. The artwork was accomplished at two long

rectangular tables in the center of the room. Though the residents could sit where

ever they wished, they usually chose the same place around the table. Their

choice was often dictated by convenient placement of wheelchairs on the near

side of the table and chairs on the far side of the table used by those who could

walk. All sessions took place on Tuesday morning from 10:30 a.m. to 12:00 noon

and were listed in the monthly and weekly calendar of events, which was

distributed to the residents. The sessions were open to all residents.

All the participants volunteered for the art therapy program and ranged

between 72-95 years of age. They decided whether they wished to attend the

sessions, for how long, and how often. The majority came from middle class


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socioeconomic backgrounds. The physical, mental and emotional challenges that

were unique to each participant are noted in individual sessions when a particular

participant is highlighted. The characteristics and diagnosis of the participants are

more fully described within the context of the individual sessions. Many had

depression, dementia, failing eyesight, failing hearing, hypertension and arthritis.

This case study discusses 15 sessions and highlights various participants noted in

the study for their artwork and or their verbal comments.

Session One: Coloring Mandalas

Materials: 8 inch x 11 inch white paper with xeroxed mandala and a variety of

colors and sizes of markers.

Directive: Share a short history of mandalas, and explain that the word mandala

means circle in Sanskrit. Discuss the relevance of circles we see and know in our

daily lives. Pass out the xeroxed mandalas and markers and ask the residents to

begin coloring in any way they choose.

Goals: (1) Encouraging exploration of creativity. (2) Expansion of manual and

visual skills. (3) Increasing feelings of accomplishment gained by finishing the

mandala to their ability. (4) Providing an opportunity to begin an informal

assessment of the residents. Ability to follow a directive, physical and cognitive

abilities, attention span, and general character of participants, were revealed

through this task that also promoted relaxation.

This was an exciting first moment, the one in which the participants


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formed first impressions. Often an impression is created from an emotional

experience, rather than from an actual event. How did they perceive this new

person, the art therapist counselor? They had not previously been exposed to art

therapy as an activity in the nursing home.

At the beginning of the session I introduced myself, explaining who I was

and why I was there. I encouraged the participants to ask questions, but this day

there were none. I emphasized repeatedly through our sessions that the

participants would be my teachers and I felt privileged to spend time with them.

This art therapy program was theirs and they were encouraged to understand that

they could say and do what they wanted, when they wanted; it was their special

time. They could come and go at any point during the session, they could make

art, observe, comment, or just be with us and they would always be welcomed.

These ideas were reviewed many times in sessions to come.

I believe that this relaxed atmosphere, allowed the residents to make their

own decisions, and follow their own desires. This method of selfmotivated

participation became established and was very therapeutic in benefiting self-

esteem. Often people would arrive in the last half-hour of the session, view the art

and listen to our process time with great satisfaction. They would then tell me

how much they enjoyed the art sessions.

Our first session started with some physical activity and became our usual

check in procedure. The participants were seated around the tables, some in wheel


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chairs, and others in chairs that were placed at the table. I explained to them that

moving the physical body helped to get blood flowing and that breathing deeply

from exercise nourishes the brain and the body with oxygen. By loosening the

physical body, a space is loosened and opened for creativity to emerge. For our

exercise, we went around the table, giving everyone a chance to participate. It was

explained that the movement could be as small as moving one finger and that each

person could respond according to his/her own ability. The first person started by

counting from one to ten during their exercise, the second person counted from 11

to 20 and the others around the table joined them with the same movement and

count. Carrying out this process proved to be challenging, but everyone did their

best. Because this session included 12 people, the count became rather high and it

took concentration to continue. I included myself in the activity. After this, we

began the art task.

Everyone was serious about their work and a hush came over the room;

talking stopped as participants concentrated on the art. Time passed quickly and I

began to learn how to budget the hour and a half we were together. It was difficult

to compute how much time to allow for clean up and processing which varied

depending on the project and the participants in any given session.

Group members were introduced to the idea of processing the artwork,

which consisted of showing their artwork to the other participants and sharing in

some dialogue. This was a new idea to the group and on this the first day it


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seemed awkward. However, everyone was willing to hold up their work and

display it. On this occasion, as during most sessions, the participants were very

complimentary of each others work. I never knew whether these compliments

were displays of compassion for other group members, or if they felt it was what I

wanted to hear. As the sessions continued, the processing conversations became

more involved on some days and almost non-existent on other days.

Figure 1. HazelsMandala.

In this first session two individuals stood out. The first was Hazel, a 93

year old Caucasian female, who suffered from dementia, hypertension, depression

and a severe hearing loss. Her ability to function fluctuated, but her attendance

level was good. Her hearing loss escalated over the course of this study and was

accompanied by increased depression. This day she comfortably began to work on


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wanted to answer but did not know how to do so. She often returned to sessions,

sometimes just to walk in the room, look around, sit down for a moment, possibly

work on some art, or walk back out of the room.

Figure 2. Velma's Mandala.

Velma would speak in Czech and repeat the same rhyme, which I have

since found out means something about, I am a Check (her spelling) girl. In

English she seemed to talk about how people were killed and how she saw terrible

things and there was a mean man and she hid from him. Upon inquiry at a later

date I found that she was born in the United States and was of Czechoslovakian

heritage. She had an 11th

grade education, had directed her own dance school, had

a son and daughter, and was widowed in her 60s. She scored 8 out of 30 on the

Mini-Mental State Examination (MMSE). A score of 23 or lower indicates


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cognitive impairment or possible dementia. She was admitted in the previous year

to the present residence from the assisted living facility, affiliated with the nursing

home. Perhaps her disclosure of the above reported incidents were events she had

been told, even as a child or a combination of events she witnessed and combined

with memories of other stories. Speculation in this area is impossible. Perhaps a

one-on-one series of session would have been helpful. I informed my supervisor

of the issues, which had been disclosed.

The session came to an end and I thanked everyone for their serious effort

and for the privilege of working with them. I informed them that I would see them

the following week. They wished me well, thanked me and after I gather my

supplies, I was on my way. I believe that the first session went well. We all got a

small glimpse of how we might work together. I still felt very new and

inexperienced with the group and knew that time was on my side to become more

relaxed and comfortable. There were 12 participants in the session which may

have been too many. This number of participants often attended the sessions. I did

not feel that it was right to limit the size of the group if residents were interested.

The participants appeared to understand that one person could only work with so

many people at a time; they patiently waited if they had a question or needed

some supplies, (save for Bernice who we will meet in following chapters). I was

not used to working with a majority of people in wheelchairs (80% of the group),

or with physical disabilities, which greatly limited the participants ability to get


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supplies for themselves or move freely about the room. I quickly discovered that

if I could help the participants learn to do things for themselves; they felt better

about the sessions. Often in a nursing home the residents are not able to take care

of their daily needs and are not given much responsibility to do so. I had learned

much about this group and looked forward to our next meeting.

Session Two: Foamy Shape Designs

Materials: 8 inch x 11 inch white paper, multi-colored foamy shapes in many

different sizes and shapes, many of which represented objects from the beach or

summer vacation, also numbers and letters, elmers white glue, large popsicle

sticks for applying glue, colored styrofoam trays for glue.

Directive: Demonstrate how to apply glue to a foamy shape and stick it down on

paper. Ask group members were asked to glue down shapes depicting a thought,

an idea, or a remembrance about a vacation they had taken.

Goals: (1) Improving and enhancing socialization skills by creating and sharing

together in the group. (2) Sharing reminiscences about a vacation to increase

cognitive ability. (3) Strengthening hand manipulation skills by applying glue to

an object and accomplishing the task. (4) Improving cognitive skills by following

multi-step instructions.

After the first session I felt that I did not yet have a good understanding of

the participants, their capabilities or their personalities. I made the decision not to

look into the nursing homes files at this time. I wanted to observe the participants


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accomplishing tasks and activities, without having previous knowledge of their

particular challenges. For the second project, I wanted to understand more about

each participants cognitive level, manual dexterity level, and the ability to follow

multiple step directives. Using glue to paste foamy shapes on paper had these

attributes. There were 8 people in this session, some from the previous session

and some new participants.

I began this session in a slightly different way than the previous session

and we held to this new format for a number of weeks. The session began by

having everyone including myself, put her name using colored marker on a peel

back sticky nametag. The residents chose the color marker they preferred. We

then went around the table and each person said her name. Interestingly, not

everyone knew the names of the others in the group. This may be in part due to

memory difficulties and may be also due to the isolation that can become habitual

with this population. We then continued around the table with our exercise

regime. This procedure served as our check in.

The materials were then passed around the table, a demonstration was

presented, and the residents got to work. In this session, as in the first session and

every session thereafter, the residents demonstrated a broad level of capabilities

both physically and cognitively. The work style and tempo also varied. Some

people finished their project in ten minutes; some had not started after ten

minutes. Once again, I chose Velmas project (Figure 3) as one of special interest.


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As in the first session, she was confused and struggling with the task. It seemed

that when she became frustrated, she started speaking in Czech, which further

removed me. Often in the following sessions she wrote unintelligible marks on

her paper. She would then ask me what the marks said, reporting that she had

forgotten or could not understand them. When we processed our work, I asked her

to read her piece and she replied that she thought it said, Go Home Lost. That

was all she was willing to say. I was touched by her disclosure and the level of

communication we shared. She appeared lost and distressed and began repeating

her favorite Czech rhyme, which she often turned to in times of confusion.

Figure 3. Go Home Lost.

Often Velma and I connected with each other during the physical

movement at the beginning of the session. When it was her turn, she had no idea

what to do. I asked her if she wanted to dance. Now? she would question.

Yes, I said. She would push her chair away from the table, standup, and do a tap


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dance routine, which she obviously knew by heart. I invited the group, mostly in

wheel chairs to move their feet and tap on the floor as well as they were able.

Velma became so involved and had such pleasure from her dance; it was often

difficult to get her to stop. By encouraging her to dance and showing her the

acceptance and appreciation of her dancing, we related and communicated if for

only a moment, which put a huge smile on her face.

Bernice in direct contrast to Velma was very verbal. A short Caucasian

female 83 years old, Bernice was always neatly dressed and often wore red flats

(shoes) with multi colored socks. She loved red and occasionally wore a red

sweater with Christmas decorations even though our sessions were not in

December. Short, straight, gray hair crowned her head and she always had a

twinkle in her eye. Her mischievous grin made me wonder, what was she

thinking? Bernice had finished high school and two years of college and had

worked as a medical lab technician. She suffered from dementia and had coronary

artery disease, a coronary bypass graft and a pacemaker. She came to the nursing

home after being in Hospice. Fortunately, at this time she was quite mobile and

only used a cane. Her MMSE score was 18 out of 30. This score was puzzling and

reminded me that getting to know a person is the most important part of any

assessment. Though her score indicated cognitive impairment or possible

dementia, I knew her to use words accurately and appropriately and to be

knowledgeable of the world around her. She easily and legibly wrote her ideas on


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her projects and always signed her work without being asked. Quick witted and

clever she always kept me hopping. Often her words had double meanings, and if

I was not paying attention I missed her intelligent puns. She was feisty,

outspoken, and full of zip and vinegar. She often swore and some of the other

women were not pleased with this behavior. It is impossible to say whether she

did this to get attention from them or perhaps from me. Unlike many others who

waited patiently she spoke out whenever she wanted something or felt like

speaking her mind. At other moments, if I did not get to her fast enough she sat

quietly and fell asleep, but woke the moment I spoke her name. Though I

witnessed her having a difficult time with some of the staff, she and I always got

on rather well. If she was not feisty and outspoken I worried about her.

On her foamy art project (Figure 4) she wrote, The stars at nite are big &

britee deep in the heart of Texas (her spelling). Bernice said that after she made

her piece the song came to mind. She suggested that the sunglasses at the top of

the page could be used to look at the bright stars, but had nothing else to say. She

was not from Texas nor did she say she had ever been to Texas. The Christian

symbolism of crosses and a fish was interesting as I did not see this repeated or

referred to again in any of our sessions, nor did I hear her speak of a strong

religious affiliation. All the members in the group belonged to different Christian

denominations.


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listen, but art therapy was unique because it allowed them to explore their creative

potential, and actually make something with their hands. The value of art therapy

in their lives seemed obvious. I learned one functional recommendation for the

future- be sure to use colored trays to hold elmers glue. White glue in a white

dish made it difficult to see the glue. It would also be possible to use foamy

shapes with sticky backs, but it can be difficult for the geriatric population to

remove the backing. Part of my plan for using glue was to have the group learn

new skills, or remember old skills, such as using glue. All these hand

manipulations help keep arthritic fingers moving, which is beneficial.

Session Three: Stamping.

Materials: various hard foam stamps, 8 x 11 paper in a variety of colors,

variety of tempera paints, styrofoam dishes for paint palettes.

Directive: After examining all the different stamp prints, select the one/ones you

like, as well as choosing the color of paper and paint you wish to use. Put your

stamp in the paint and then on the paper. Tell a story with your artwork.

Goals: (1) Create decision making opportunities that lead to fostering a sense of

self as well as encouraging involvement and experimentation. (2) Encourage

verbal interaction by asking participants to tell a story that evolved from the

stamps they used. (3) Increase socialization.

The session began again with nametags and physical movement exercises

experienced around the table. I observed that many of the participants were


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becoming familiar with the check in procedures. There are times when strict

adherence to a schedule and established routine is very helpful in providing

stability with dementia patients, like those in the art therapy group. However, this

group appeared to possess enough stability to introduce a new component during

the check in ritual. This new component was a silent moment of gratitude for all

that we have. By this time I began to see that religion was very important to many

members of the group. A priest came to say prayers with the Catholic residents

and I noticed that some participants of the art therapy group joined in these

prayers. During a previous internship the art therapist asked for a prayer of

gratitude before beginning each session. This idea touched me and I felt that it

lent a special meaning to the sessions. I explained that this practice was not

affiliated to any particular religion; it was just giving thanks for the opportunity to

come together and be creative in a beautiful, peaceful surrounding with plentiful

supplies and to feel joy in sharing creatively with each other. We each took a

silent moment for personal thoughts after which we began the session. I believe

that the group was receptive to this moment.

There were ten people in this session. Everyone selected their paper,

stamps and paint and began after a demonstration. This project took on a playful

quality that differed from the silence which marked previous weeks. The residents

and I conversed and visited in a relaxed manner. There was a delightful interplay

between Bernice and the woman sitting next to her, Vivian. Bernice quickly


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covered her paper with ladybug shaped stamps (Figure 5) and wrote, The bugs

are coming! Vivian saw what Bernice was doing.

Figure 5. Bernice's Bugs Are Coming.

Vivian was a Caucasian female age 86 years old. She had arthritis and

hypertension and was the only person in the group with an electrically powered

wheel chair, which she handled with ease. Always nicely and neatly dressed with

a comforter over her legs, she explained that she was often cold and this caused

her arthritis to be more painful. She had lovely gray hair in a bob, just below her

ears. The size of her blue eyes was increased by her large framed glasses, giving

her a look of wide eyed wonder and curiosity. Pleasant and interested in the art

tasks, she always smiled and added an observant comment. She functioned at a

high level cognitively. Vivian had been a professional portrait painter and


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graduated from art school. A loyal supporter of the art therapy program; she

enjoyed the sessions and the variety of media and interventions.

Vivian responded (Figure 6) to Bernices artwork by stamping the same

ladybug shape in the same color as Bernice had done. Then Vivian stamped trees

around the bugs and said the title of her piece was, Bernices Bugs in the

Forest. She exhibited a great deal of creativity, interaction with another group

member, and true spontaneity; her cleverness gave everyone a good laugh.

Figure 6. Vivian's Bugs in the Forest.

Ellen also gave us a good laugh. Ellen was a 91 year old Caucasian

woman. At the time she had entered the nursing home two years ago she had

scored 20 out of 30 on the MMSE. A score of 23 or below indicates cognitive

impairment and possible dementia. She was in a wheel chair and suffered from

hypertension, depression, colostomy complications and dementia. During the time

of this study she contracted a serious infection and eventually went to Hospice. I


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am happy to report that I recently visited her, she is out of Hospice and she has

made a substantial physical recovery, but she suffers from severe depression.

Hopefully she may rejoin the group.

Figure 7. Ellen's Stamp Art.

Ellen used a variety of stamps and colors on her project (Figure 7). During

processing, she said, If I had known we were going to tell about it, I would have

done a better job. This really said something about the idea of processing and

sharing. There was great value to showing and talking about the work with the

group. Ellen was a real spitfire and added lots of energy to the group. Sweet,

considerate and grateful for our attention, she always wanted to kiss the nurses

and me and tell us how much she loved us. On the other hand as witnessed in her

processing, she had a sharp wit and spoke her mind. Unfortunately, she often had


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little energy and was unable to attend many sessions.

The stamping project achieved its goals of fostering creative decision

making and socialization; it encouraged members to talk more freely and to play

with each other. I learned that hearing loss is a big adherent to promoting better

socialization skills. Conversations between two people sitting next to each other,

often failed; because they were not looking directly at each other, they did not see

lips move. This inhibited the recognition that someone was speaking to them. If

an attempt was made to speak to someone and they did not receive a reply, it was

not common to try again. Thus the communication line was stopped before it was

even started. During the session I moved around the room when I spoke, focusing

my attention on different participants, trying to give everyone a chance to hear. I

also repeated what a participant had said for clarification. The ability of the

members to hear was not always constant. Someone who had difficulty hearing

me at the beginning of the session suddenly heard me at the end of the session

when I was further away. Was this an example of selective hearing, not focusing,

perhaps losing or gaining interest? I can not say.

These physical limitations played an important part in the success of the

sessions. In addition to hearing difficulties, there was visual impairment. During

our process time I often held up the artwork and walked around the table to be

sure everyone could see. The residents also informed me of another problem: the

table height. They explained it was not always easy to get close to the table with


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some wheel chairs. On the other hand if the table was too high it was difficult for

some of the residents to raise their hands or arms up to the height of the table.

These obstacles all have bearing on participation. I solved many of these

problems by simply asking the members what worked best for them and then

implementing solutions.

Session Four: Person in the Rain

Materials: 11 x 17 white paper, variety of colored markers.

Directive: Draw a person in the rain.

Goals: (1) Informal assessment, (2) Opportunity for participants to increase

cognitive functioning by thinking about a particular situation they have not

experienced in a long time specifically, being in the rain, and recreating that

situation visually. (3) Observing the visual symbolic representation of how

participants they take care of or protect themselves.

It was raining very hard during this session and I decided it would be a

perfect opportunity to do an informal person in the rain assessment. We began

with our usual check in procedure. There were only 8 participants present in this

session. I think the rain kept many people in bed, as it was dark and stormy at

10:30 a.m. Everyone thought the project was a good idea, and went right to work.

All of the artwork created in this session was interesting. I have selected

three pieces to review. The first piece was done by Deborah, a Caucasian female

and at 72 years old the youngest in the group. Having previously been a model,


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she was very concerned with her appearance. She had long gray-blond hair almost

to her shoulders and always wore lipstick. One time when she could not think of a

physical movement for check in, I suggested she put on lipstick, something she

did easily with no hesitation or thought. Due to Alzheimers disease, however, her

lipstick was often inaccurately applied. Clothing combinations she selected were

slightly off, mixing checks with plaids, or other prints in a variety of unmatched

colors with multiple Mardi Gras type purple or green plastic necklaces. It was as

though she was making one last gallant attempt to wear as many of her clothes as

possible. Her attire was almost clown like, but her face was a mask of confusion. I

always complimented her outfits, which greatly pleased her. She scored 12 out of

30 on her MMSE. A score of 23 or below indicates cognitive impairment and

possible dementia.

Deborah showed visible signs of Alzheimers progression during the time

I did this case study. At the beginning she came for each session and stayed for

the entire time. Gradually she became less and less able to understand the

directives and then did not attend the sessions or came into the room and

wandered out after a half an hour. At other times she would stay for the whole

session and exhibit clear thinking. When Vivian fell, badly bruising herself,

Deborah taught me an important lesson by suggesting that we make get well

cards. What a wonderful form of healing therapy. Deborah asked if she could


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deliver the cards to Vivian and she accomplished this task. She created her own

device for gaining self-esteem.

This day Deborah stayed for most of the session. She did not put a person

in her drawing (Figure 8). I believe the title of her work Cats and Dogs explains

her reasoning and is the result of my encouraging the group to think of words that

they associated with rain. Its raining cats and dogs. was mentioned. The other

word Deborah told me she wrote was teardrops; she said she did not know how

to spell it. She only used a blue marker.

Figure 8. Deborah's Person in th

geriatric group art therapy

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